It is strongly recommended that all individuals with pulsatile tinnitus locate an excellent physician with interest in the circulatory system and complete a thorough examination.
Based on my research this spring, which included reviewing 7 otolaryngology textbooks and over 250 research studies, the data appears to support the underlying cause for detecting a pulsatile tinnitus as physiologic in nature. That said, there are many, many cases of pulsatile tinnitus that defy diagnosis and identification of the causative agent.
Here are some general facts about this troubling condition:
Pulsatile tinnitus is most often classified as objective tinnitus, meaning that others may also hear the sound, using a stethoscope or other sophisticated equipment.
Dr. Abram Shulman, who directs the prestigious Martha Enteman Tinnitus Treatment Clinic in NYC, writes: "Objective tinnitus can be experienced by the examiner on auscultation of the auditory canal and/or of surrounding structures with use of an auscultation tube or stethoscope. The find on auscultation of a carotid bruit (noise) or a vascular bruit overlying the orbit and/or cranium may be a reflection of an arteriovenous (AV) malformation or fistula."(quote from Essentials of Otolaryngology, Third Edition).
Pulsatile tinnitus can also be related to the following conditions:
From Otolaryngology Head and Neck Surgery, Eighth Edition, the chapter written by Dr. Alexander J. Schleuning II (who practices at OHSU in Portland, Oregon). The notes in parentheses are my explanatory comments.
Pulsatile tinnitus can be heard as several characteristic sounds including a lower pitched thumping or booming, as well as a rougher blowing sound which is coincidental with respiration, or as a clicking, higher pitched rhythmic sensation. Finally there may be single, rhythmic beats, or multiple biphasic beats (like the clip-clop of the horse), or a swishing, swooshing sound.
A rapid clicking sensation may be due to the contractions of the middle ear and palatal muscles. Low humming tinnitus that is inaudible to the examiner may be due to venous blood flow or associated with Meniere's disease when accompanied by vertigo and fluctuating hearing loss.
Objective tinnitus that is strongly associated with the timing of the heart beat is most likely the product of a blood vessel malformation of the arteries and veins of the head or neck area. These blood vessels are located adjacent to the ear on the surface of the head or just inside the head. These cases require special imaging techniques and often require surgery to resolve.It is my sincere hope that everyone who experiences pulsating tinnitus will pursue a thorough medical evaluation to locate the cause, if possible. The research is full of reports about methods for repairing the problems that create this disturbing symptom. At the same time, there are many cases of pulsatile tinnitus, which are not pinpointed, and these tend to fall into the idiopathic category (meaning unknown causes). Individuals who find that the initial imaging results do not reveal abnormalities should insist on further examination and investigation. It is apparently possible to misread or miss these trouble spots that may be tangled in other structures or hidden by bone or other tissue. Newer techniques have been employed that help determine the site of lesion in the majority of cases.
Based on the numerous studies, some listed below, and others, which revealed similar or identical data, the cure rates for PT are quite high, once the problem area has been identified.
These are arranged by year of the study. Authors are cited, as are important findings. Studies were included based on the amount of information, introduction of new techniques or diagnosis, or the number of patients included in the study. Authors' names and year of publication are included, and the original studies may be located by finding access to MEDLINE database (use your Internet search engines to locate an access point). Abstracts of most studies are located on Medline, for the entire article you will need to order through a internet document provider, go to your nearest medical school library, or access a medical library via internet such as LonesomeDoc service offered by OHSU here in Portland, Oregon.
For a more complete list, obtain a medical terminology dictionary from Amazon.com or Barnes & Noble.
PT = pulsatile tinnitus
AV = arterio-venous (connection between an artery and a vein)
Fistula = aberrant opening between two entities
Embolization = surgical closures of arteries or veins, in addition, tying, cutting or cauterizing may be utilized.
For aneurysms, tying, clamping, or clipping off the ballooning portion
Pulsatile Tinnitus and Angioplasty and Stenting of
the Petrous Carotid Artery--tinnitus that results from
blood flow turbulence was corrected using angioplasty
(using a tiny balloon to press open a partially closed
blood vessel)---------- and stenting (inserting a new
artificial blood vessel wall).
Emery, Ferguson, Williams, 1998
Two pts. were found to have primary paragangliomas
of the facial nerve canals. Both pts. had facial
paresis or pulsatile tinnitus.
Petrus, Lo, 1996
Two pts. with Arnold-Chiari malformation
(a blood vessel malformation) and one pt. with
a congenital stenosis (narrowing) of the sylvian
aqueduct had pulsatile tinnitus. Intercranial
hypertension was a primary complaint in all
3 cases. Decompression surgery in one pt. relieved
the symptom. This study documents cases of
congenital central nervous system defects which
can cause PT.
Wiggs, Sismanis, Laine, 1996
A dural (sac around the brain) malformation
resulted in PT and was located using computed
PT presented in a pt. as a symptom of pseudotumour
cerebri (intracranial hypertension syndrome)
Petrus, Lo 1996
Three cases of dural AV fistula with PT reported
treated successfully by embolization surgery.
Angiography of the carotid and vertebral arteries
should be performed to judge source of blood
flow and drainage.
Morales, Rama, Diez, Quintana, de Saro 1996
Magnetic resonance angiograph and venography
of tumors and vascular compression lesions
recommended for diagnosis of PT.
Van Hemert, 1997
AV fistulas including transverse and sigmoid
sinuses in 30 patients who underwent panangiography.
Bruit (blood vessel noise), PT and headache
were the most common symptoms. Embolization
was performed in all cases except one where
baloon occlusion of the transverse sinus was
attempted. 18 pts. were cured, 11 were improved
and 1 was unchanged. Complications from the
surgeries included transient stroke (1), transient
facial paralysis, and a slight skin infection.
Olteanu-Nerbe, Uhl, Steiger, Yousry, Reulen 1997
An dural AV fistula in the left transverse
sigmoid sinus with PT was reported in 1 case.
MRI showed a mass and embolization was completed.
Matsugama, Noguchi, Kakizaki, Kashihara 1997
PT in a female for 14 years was found to
have jugular megabulb of the right side, discovered
during exploratory surgery.
Abilleira, Rmoero-Vidal, Alvarez-Sabin, Ibarra, Molina, Codina, 1997
Neuro vascular decompression of the VIII
cranial nerve in 10 pts. with facial spasms
and one-sided tinnitus. Tinnitus was markedly
improved in 8 pts. and both PT and continous
tinnitus improved. Pts. did experience hearing
Ryu, Yamamoto, Sugiyama, Uemura, Nozue 1998
One pt. with PT and hypertriglyceridemia whose imaging
tests revealed a high position enlarged jugular bulb
with slowed blood flow.
Lopez-Escamez, Gamero, Castillo, Amador 1997
Intracranial hypertension can cause audible PT.
Biousse, Newman, Lessell, 1998
PT of a one-sided nature was found in a person
with dopamine-secreting glomus jugular tumor.
Other side effects included palpitations and
Troughton, Fry, Allison, Nicholls, 1998
Eighty four pts. with PT over a 10 year period
received non invasive imaging examinations.
Thirty six were found to have a vascular disorder
(42%), most commonly a dural AV fistula or
a carotid-cavernous sinus fistula. In 12 pts.
(14%) there were nonvascular disorders such
as glomus tumors or intracranial hypertension.
PT pts. should receive non invasive techniques
first, then followed by angiography as need.
Waldvogel, Mattle, Sturzenegger, Schroth, 1998
One case of a malformed carotid artery which
was eroding the bony capsule of the inner ear
is cited as an unusual case of PT.
Yao, Benjamin, Korzec 1998
Thirteen pts. with AV fistulas of the external
carotid artery were treated with endovascular
emobolization. Most frequent symptom was PT,
followed by bruit, visual problems, headache,
and a pulsatile mass in the neck. Trauma caused
the fistula in 10 of the pts. and occured spontaneously
in the other 3 pts. All the pts. were cured
following the surgery and there were no signficant
Luo, Lirng, Tneg, Chen, Guo, Chang, 1998
One pt. with injury reported a PT and swelling
in the area in front of the ear. An AV fistula
was identified and surgery resulted in improvement.
Intercranial hypertension identified with
headache and PT in 25 obese pts.
Wang, Silberstein, Patterson, Young 1998
PT in a man with head injury and headache
reported. Behavioral interventions were used
to modify his distress along with lifestyle
changes, and the value of polygraphic assessment
for evaluating treatment outcomes is stressed.
Hegel, Martin 1998
PT over 15 years in 145 pts. was studied.
Evaluations were individualized and included
radiologic testing, ultrasound, and spinal
taps. Benign intracranial hypertension syndrome
was the most common diagnosis (56 pts.). Carotid
artery disease was next (24 pts.) and glomus
tumors third most common (17 pts.). In 13 pts.
a diagnosis could not be reached. Conclusion
is that the majority of pts. with PT have a
treatable underlying etiology.
Nine pts. were found using MRA to have excessive
carotid artery, vertebral artery, and vertebrobasilar
artery twistings. The pts. complained of migraine,
PT or carotidynia.
Pelaez, Levine, Hafeez, Dulli, 1998
Transverse/signoid sinus dural AV fistulas
are difficult to diagnose or locate using current
technology. PT is the main symptom. Forty one
pts. were evaluated and classified into 4 grades
depending on their situations. Treatments included
compression therapy, embolization, surgery.
PT was the chief complaint in 90% of these
cases. Angiography was the best tool for evaluation
and MRI is much better to CT when scanning
for fistulas. 82% of the pts. achieved resolution
of the PT, and half ended up with obliteration
of the fistula via surgery.
Shag, Lalwani, Dowd, 1999
A 29 year old woman with PT and poor hearing
revealed a mass in the middle ear which proved
to produce PT. This proved tobe an aberrant
internal carotid artery coursing through the
middle ear space.
Koizuka, Hattori, Tsutsumi, Sakuma, Katsumi, Kikuchi, Kato 1998
Jugular bulb was found to divert into the middle ear
space or towards the petrous pyramid close to the inner
ear in 4 cases: PT was a major symptom.
Presutti, Laudadio, 1991
Ten obese pts. with idiopathic intracranial
hypertension including symptoms of daily headaches
and PT were followed through various treatment
Marcelis, Silberstein, 1991
37 million Americans suffer from tinnitus
associated with high fq. sensori neural loss,
which may lead Mds to overlook serious underlying
conditions associated with one-sided tinnitus,
PT, fluctuating tinnitus or tinnitus associated
Marion, Cevette, 1991
PT in a patient revealed mass in the tympanic
space, surgery revealed a large artery situated
on the bony promontory in the middle ear which
proved to be the internal carotid artery.
Fukuda, Penido, Munhoz, Mota, deOliveira 1991
Traumatic AV communications review which
can cause swelling of the face with PT as a
main symptom. Management is suggested as complete
excision and ligation of the arterial feeding
vessels. One case is reported.
Lbeau, Reychler 1991
A 57 year old male with PT and one sided
hearing loss with one sided facial palsy had
a mass in the right ear on the middle fossa
near the geniculate ganglion. t was an tumor
fed by the meningeal artery, and was removed
Senke, Sasaki, Ohta, Sinohara, Takeda, Matsui, Ueda, Furuga, Murakami 1991
73 cases of glomus tumors were studied over
30 years, PT was the primary symptom in 1/2
of the pts. with hearing loss in 1/3 of the
pts. These cases required diagnostic evaluation
using high resolution CT as the number one
choice. Surgical approach was used with few
complications. Recurrence rate was less than
O'Leary, Shelton, Giddings, Kwartler, Brackman 1991
PT as a rare sign: characterized by rhythmic
sound synchronous with heart beat., underlying
causes vary widely, some may be life threatening.
Major causes cited are cardiac or vascular
malformations, metabolic disorders, hyperdynamic
circulatory states, elevated intracranial pressure
and tumors. Pts. need phsycial examination,
audiologic assessment, CT scans for images.
1 case hx reported.
Mahlo, Kellermann, 1991
Review of tinnitus, subjective and objective,
and techniques for evaluating condition are
discussed based on different pathologies: retrotympanic
masses, retrocochlear lesions, cochlear abnormalities,
infection, cholesteatoma, acquired vascular
abnormaility (accidents), and more.
36 pts. with glomus tumors of the temporal
bone were operated on: PT, hearing loss, and
paresis of the lower cranial nerves were present
most often. High resolution CT scanning was
used. Results showed a need for earlier diagnosis.
Lenarz, Plinkert, 1992
A 57 year old male
sufferent from PT and vertigo attacks with
right sided facial spasm. Treatment had been
completed for attacks of Meniere's syndrome
which was not effective. A CT scan and vertebral
angiography revealed an enlarge vertebral
artery and compression of the VII and VIII
cranial nerve was suspected. Decompression
surgery was perform and the PT, dizziness,
and spasm disappeared.
Ohashi, Yasumura, Nakagawa, Misukoshi, Kuze 1992
Aberrant internal cortid arteries in middle
ears can manifect vertigo, tinnitus, or hearing
loss. Red or blue mass seen behind the eardrum
is one clinical finding: PT may be present.
View can be obscured by ear infection, etc.
and required radiological studies prior to
Campbell, Renner, Estrem 1992
AV of the ascending pharyngeal and internal
jugular vein is rare but may present with PT.
Chaloupka, Kibble, Hoffman 1992
Objective tinnitus can be caused by a vascular
abnormality of the cervical region, skull base,
or intracranium. Flow can be perceived as PT.
Aberrant carotid artery, high riding jugular
bulb, or a glomus tumor can produce PT. Other
causes of PT include: arteriovenous malformations,
atherosclerotic vascular disease, intracranial
tumor with elevated cerebrospinal fluid pressure.
Aneurysm presenting with PT is extremely rare:
only 8 have been identified to date in the
Austin, Maceri, 1993
A jugular glomus tumor arises from the glomus
bodies located in the adventitia of the dome
of the jugular bulb. Resembles a carotid body
tumor closely. A 41 year old women with PT
and uncontrollable high blood pressure is reported.
Following surgery and removal, blood pressure
Maasen, Lenarz, Ruck, Bien, Overkamp, Kaiserling, 1993
Cysts in the petrous bones associated with
PT and palsy were studied.
Jaeger, Bonafe, Fraysse, Manelfe, 1993
Vascular malformation responsible for PT
in 2 cases with dural AV malformation and high
riding jugular bulb. Techniques for diagnosis
Stenglein, Cidlinsky 1993
PT in an unusual case of iatrogenic AV malformation
following a myringoplasty and following surgery.
Evaluation and diagnosis of PT underlying conditions
is stressed, especially angiography in addition
to evamin, otoscopy, audiology, and CT scans.
Agrawal, Flood, Bradley 1993
Embolization of a dural AV fistula which presented
with atypical facial pain and rightsided PT for 10 years.
This same defect was present in other family members,
and surgry resolved the compression of the trigeminal
nerve and resolved the PT.
Ott, Bien, Krasznai 1993
PT and AV fistula reported in France. Vascular
radiography revealed the defect. Another case
of AV in the occipito-sinus area with PT is
Machini, Kennel, Hermann, Piller, Hemar, Conraux 1993
Study reports cases of vascular anomalies
include intra and extra cranial AV malformations
and glomus jugulare tumors as being main causes
of PT. Benign cranial hypertension is also
identified as a cause. PT may also present
as a humming resulting from venous flow with
a one sided effect. Ligation (tying off) of
the internal jugular vein appears to be a successful
Nehru, al-Khaboori, Kishore 1993
Review of a high jugular bulb is not uncommon
in the temporal bone, five cases are discussed
and 52 cases reviewed. Most often the condition
occurs on the right side with PT and may be
present with an abnormal bone formation, aberrant
sinusjugular system or decreased pneumatization
(air pressure) of the mastoid bone. Most people
with this condition, however, do not experience
PT. High resolution computerized tomograph
scan is the most convenient tool for imaging.
Exploratory tympanomotomy is not recommended
and jugular vein ligation has been reported
with good results. Regular long term follow
up for pts. without symptoms is recommended.
Lin Hsu Lin 1993
Discusses arterial dissection with bleeding
into the vessel walls: associated with crevical
trauma or underlying vascular disease. The
internal carotid artery is most comon side
and can occur in young or middleaged adults,
most common symptoms are head or neck pain,
PT, palsy, headache, and possibly stroke. Angiography
is used to determine the defect, and there
is a risk of cerebral complications can result.
MRI is non invasive and ultrasound is developing
which are increasingly used.
Aberrant internal carotid artery is a young
woman with PT and hearing loss is diagnosed
using a CT scan and angiography. A large persistent
stapedial artery was present with stapes bone
fixation of unknown cause. Stapedectomy was
performed and PT resolved.
Pirodda, Sorrenti, Marliani, Cappello 1994
PT can present problems: 100 pts. with PT
are reviewed and the use of magnetic resonance
angiography discussed. With MRI, PT diagnosis
has been advanced considerably. Cerebral angiography
is presently indicated in only a few cases.
Cited as major causes are intracranial hypertension,
glomus tumors, carotid atherosclerosis.
Sismanis, Smoker 1994
Imaging techniques for PT examination are
discussed in detail.
The use of MR imaging and MR angiography
for PT diagnosis is discussed and 49 cases
are cited. 28 pts. showed vascular lesions
or paraganglioma, with the majority seen best
with MRA. Lesions included dural AV defects
(9), extracranial AV defects (3), paragangliomas
(5), jugular bulb variations (3), aberrant
internal carotid arteries (1), internal carotid
artery stenosis (narrowing) (1), tortuous (twisting)
internal carotid artery (1), carotid artery
dissection (separation) (1), transverse sinus
stenosis (2) and and AV malformation (2). MRA
with spin-echo imaging, markedly enhances the
ability of MR to diagnosis PT.
Dietz, Davis, Harnsberger, Jacobs, Blatter 1994
54 pts. were followed after angiography to
find intracranial hemorrhage and AV fistulae.
Risk of hemorrhage for brain damage with dural
AV condition was 1.6% during almost 7 years
(the length of the follow-up period). Potential
predictors of brain damage included lesions
of the petrosal sinus and straight sinus. PT
improved in more than half of the pts. and
resolved in 75% following surgery during the
period of the study. Pts. without sinus or
venous outflow blockage discovered during the
initial imaging were more likely to improve
or remain stable that pts. with an occlusion.
Brown, Wieberg, Nichols, 1994
Objective tinnitus usually has a vascular origin, but
dural (brain casing) AV fistulas are rare--here is a
case of an AV meningeal fistula of the lateral sinus
with PT. This condition is discussed along with diagnosis
and treatment strategies.
Morais, Sancho, Garcia-Porrero, Bachiller, Alonso-Vielba, Miyar 1994
High Resolution Computed Tomography is
needed for pts. with temporal bone disease---8
cases discussed and clinical conditions included
PT, hearing loss, etc. etc.
Tan, Lim, Boey 1994
Audiologic findings in glomus tumors is discussed:
hearing loss, PT, retrotympanic mass.
Baguley, Irving, Hardy, Harada, Moffat 1994
Discussed which techniques should be used in magnetic
resonance imaging for diagnosing PT.
12 cases of atherosclerotic artery disease
and PT were reported with stenosis (narrowing)
of the vessel in all cases. This should be
highly suspected in pts. with PT older than
50 years and have associated cardio vascular
risk factors. PT can be the first manifestation
of the disease. Ultrasound studies of the carotid
arteries can confirm the diagnosis and a vascular
surgeon should be consulted.
Sismanis, Stamm, Sobel 1994